The number of new or revised
Med Learn (MLN Matters)
articles released this week. All
new and previous Med Learn
articles can be viewed under
the type "Med Learn", in the
Advisor tab of the PARA Dat a
Edit or . Click here

We are getting Medicare denials for Tdap provided in our clinic given as preventive,
without an injury/wound. However, when I look in PARA there is a Part B payment of
$30.95, but there are no NCD or LCD policies for NGS, Jurisdiction 6, to indicate medical
necessity limitations or specific indications. Can you please explain what I'm missing?

Answer: The most basic principle of Medicare Part A and Part B is that coverage is
limited to only medically necessary services; the only exceptions are specific preventive
services mandated by law ? literally by an act of Congress. These preventive services
are listed in a table within the Medicare Claims Processing Manual, Chapter 18 Preventive and Screening Services.
Here?s a link, the table of preventive services is too long to repeat here:
https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/clm104c18.pdf
If the Tdap booster shot is considered medically
necessary, for instance for a patient with a
recent puncture wound, Medicare pays at the
rate you identified on our website.
However, in the absence of a diagnosis for a
condition that warrants the vaccine, Medicare
Part A and B does not cover Tdap, and the claim
will be denied.
That being said, prescription coverage under
Medicare Part D typically offers coverage for
preventive injections, including Tdap.
We recommend instructing Medicare patients
who seek a preventive Tdap vaccine in the
absence of a specific medical need (i.e. a specific
risk due to a recent wound) to seek Tdap booster
shots at their participating Medicare Part D
pharmacy.

2

PARA Weekly Update: November 7, 2018

NERVE BLOCKS

Regarding nerve blocks given for post-op pain charging, we have two questions.
1) If done in PACU before going to OR is it appropriate to charge 64415 for the facility
fee and CRNA fee?
2) If done in the OR is it appropriate to charge 64415 for the facility? Currently the
facility charge is dropping with Revenue Code 761.
Answer: I have attached our paper on billing for nerve blocks; we updated it this year
when we learned that separate reimbursement for nerve blocks is frequently denied by
commercial payers. The rationale for the denial is that all postoperative pain
management is the responsibility of the surgeon, and should not be separately reported
except in unusual circumstances.
Our research indicates that nerve blocks which are performed by an anesthesiology
professional for postoperative pain management are separately billable with modifier 59 or XU (unusual
non-overlapping service) if all of the following criteria are met:
1. The block is performed by a physician which is NOT the surgeon performing the surgical
procedure for which the analgesia is desired;
2. The surgeon?s documentation provides a
valid reason for requesting the
anesthesiologist/CRNA to perform the
service instead of performing it him/herself.
For example, the technical difficulty of the
block due to unusual anatomy may require
the advanced technique of a trained
anesthesiologist/anesthetist;
3. The performing physician?s documentation
clearly establishes that the anesthesia
required for the procedure is not dependent
upon the peripheral nerve block; The nerve
block procedure is fully documented as
separate and distinct from the anesthesia
and the surgical procedure. Depending on
the surgical procedure performed together
with the nerve block, you may find that the
two codes hit a CCI edit.
For detailed information download our PARA
article here:
https://apps.para-hcfs.com/para/Documents/
Billing%20Nerve%20Blocks%20for%20Postop
%20Analgesia%20-%202018%20Update
.pdf

3

PARA Weekly Update: November 7, 2018

STERILIZATION FORM

We have a claim in which the consent form for sterilization was not completely filled out
properly and our facility is wondering if there is a code that we can place on the claim
to show that we didn't obtain complete medical necessity for the services? We are
wanting to place the code on the claim and adjust the charges related to the service for
which we didn't obtain the complete medical necessity, but bill the rest of the services,
is this something that we are able to do?
Answer: We could not find information that was on point to the issue within the Indiana
Medicaid provider manuals. Depending on what the other services were, we found an
excerpt which instructs providers to append a modifier (i.e. XP/XS/XU/XE) to the
unrelated services code.
http://provider.indianamedicaid.com/media/155520/family%20planning%20services.pdf

We found the box in the excerpt below
and searched the ?Member Eligibility and
Benefit Coverage? guide, but found no
additional instruction there.
http://provider.indianamedicaid.com/media/
155520/family%20planning%20services.pdf

4

PARA Weekly Update: November 7, 2018

STERILIZATION FORM

Here?s a link to the referenced Member Eligibility and Benefit Coverage manual, in case you?d like to
check it out:

In addition to appending a
modifier to the procedures
you hope will be covered,
we recommend appending
modifier GY or GZ to the
sterilization procedure; that
modifier is listed in the
Indiana Medicaid manuals:
http://provider.
indianamedicaid.com/ihcp/
Publications/providerCodes/
CMS-1500_Modifiers.pdf

5

PARA Weekly Update: November 7, 2018

C REACTIVE PROTEIN

I have been having difficulty with an ABN that we talked about some time ago
involving the medical necessity for C reactive protein. This test, according to our
Medicare contractor, Noridian, is denied because it is associated with a Prometheus
Panel for IBD.
According to our LIS system, only Montana has a ruling about this test. I am trying to
order just the single test of C reactive protein and it is not part of the Prometheus Panel.
I have been told that I have to contact Noridian about this problem. Can you help me
identify a contact at Noridian?
Answer: If we're not mistaken, the policy that is causing you heartburn is LCD L37313
regarding 86140 (C-reactive protein); it is in effect in all of the Jurisdiction F states as of
1/30/18:

6

PARA Weekly Update: November 7, 2018

C REACTIVE PROTEIN

To communicate with the MAC, we might suggest that you ask to participate in the Contractor Advisory
Committee (CAC) meetings for your state. All the MACs are required to establish CACs in developing and
finalizing LCDs. Here?s the webpage and the contact person for the Noridian?s CAC page:
https://med.noridianmedicare.com/web/jfb/policies/lcd/cac#membership

7

PARA Weekly Update: November 7, 2018

C REACTIVE PROTEIN

According to the published document, L37313 was discussed in CAC meetings in each state prior to its
effective date:

Here?s an excerpt from the current LCD explaining why they won?t cover the tests:
https://www.cms.gov/medicare-coverage-database/details/lcd-details.aspx?LCDId=37313&ver
=7&CoverageSelection=Local&ArticleType=All&PolicyType=Final&s=Montana&CptHcpcsCode
=86140&bc=gAAAACAAAAAA&
?Analysis of Evidence
(Rationale for Determination)
?Level of Evidence
Quality: Poor
Strength: Moderate
Weight: Moderate ?Although
manufacturer data supports
clinical validity of the test for
diagnosing IBD, this evidence is insufficient to support an indirect chain of evidence for clinical utility due
to lack of details about study methodology and lack of replication of the findings. For distinguishing UC
from CD, clinical validity has not been established. No studies examining the clinical utility of IBD sgi
Diagnostic? have been identified. Furthermore, there are no US Preventive Services Task Force
(USPSTF) recommendations for genetic or molecular testing for inflammatory bowel diseases, and no
8

PARA Weekly Update: November 7, 2018

C REACTIVE PROTEIN

recommendations for multi-marker panels that include genetic tests to facilitate diagnosis or prognosis of
CD or UC.4, 5 Consequently, this assay does not meet Medicare?s reasonable and necessary criteria for
coverage. Additionally, each of the individual components that comprise this assay, except ASCA-IgA,
ASCA-IgG, and atypical perinuclear anti-neutrophil cytoplasmic antibody, are additionally non-covered for
the diagnosis of IBD.?

9

PARA Weekly Update: November 7, 2018

DOWNLOADABLE CMS FINAL RULES AND OPPS FACT SHEET

CM S has issued some final rules and a fact sheet w ith changes that become
effective in 2019. Click on the "hand" next to the press release and fact sheet
you w ish to dow nload.

10

PARA Weekly Update: November 7, 2018

MEDICARE ISSUES AUDIT GUIDELINES ON LAB ORDERS

Medicare released an update to the Program Integrity Manual on October
19, 2018 to provide guidance to auditing entities on verification of the
physician order for laboratory tests. The guidance should be of interest to
providers working to ensure that current lab order documentation practices
will meet Medicare guidelines. A link and the pertinent excerpt from the
transmittal is provided:
https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/2018Downloads/R836PI.pdf

42 CFR ยง410.32 states that all diagnostic x-ray tests, diagnostic laboratory tests, and other diagnostic
tests must be ordered by the physician who is treating the beneficiary and that tests not ordered by
the physician who is treating the beneficiary are not reasonable and necessary.
Pub. 100-02, Chapter 15, Section 80.6.1 states that while a physician order is not required to be
signed, the physician must clearly document, in the medical record, his or her intent that the test be
performed.
Contractors shall consider order requirements for diagnostic laboratory tests met if there is:
1. A signed order or signed requisition listing the specific test; or
2. An authenticated medical record that supports the physician/practitioner?s intent to order tests (e.g.
?order labs, ?check blood?, ?repeat urine?). See Pub. 100-08, Chapter 3, Section 3.3.2.4 for
authentication requirements.
Regardless of how the order requirements are met, contractors shall verify that the supporting
authenticated medical record documentation contains sufficient information supporting the
ordered/provided tests are reasonable and necessary per 42 CFR ยง410.32.
Note: As noted in Pub. 100-02, Chapter 15, Section 80.6.1, if the order is communicated via
telephone, both the treating physician/practitioner or his/her office, and the testing facility must
document the telephone call in their respective copies of the beneficiary?s medical records.
11

PARA Weekly Update: November 7, 2018

FREE DOWNLOADABLE BOOKLET FROM CMS

CMS has published a new, easy-to-read booklet entitled "Items And Services Not Covered Under
Medicare", explaining four categories of items and services not covered under Medicare. It's important
information for all Medicare fee-for-service providers.
Get it here:
https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/
Downloads/Items-and-Services-Not-Covered-Under-Medicare-Booklet-ICN906765.pdf

12

PARA Weekly Update: November 7, 2018

2019 CODING UPDATE DOCUMENTS -- NEW DOCS ADDED TO PDE

In pr epar at ion f or t h e year -en d CPT® / HCPCS u pdat e, PARA h as pr epar ed a n u m ber
of sh or t , on e t o t w o- page ?2019 Codin g Updat e? docu m en t s list in g delet ed codes
an d added codes w it h in a par t icu lar clin ical ar ea or pr ocedu r e gr ou p. M or e paper s
h ave been added du r in g t h e m on t h of Oct ober , 2018.
The coding topics addressed do not encompass all CPT® updates, only those which are most likely to be
?hard-coded? to a line item in a facility chargemaster. Topics are divided into immediately related areas,
and more than one paper may contain information useful to a service line manager.
Due to CPT® licensing restrictions, these documents cannot be published within the PARA Weekly
Update. PARA Data Editor users may access the information on the Advisor tab; search ?Coding
Update? in the type field, and/or 2019 in the subject field, as illustrated below:

Documents may be updated as we learn more information about the new codes; updates will be
announced in the PARA Weekly.
It is important to note that we do not have Medicare coverage information on the new codes at this time.
Following the release of the OPPS Final Rule in November, coding update papers may be revised to
indicate whether Medicare will accept/cover new HCPCS. PARA Data Editor users can identify updated
papers by the word ?Revised? in the title and the date issued will be updated.

13

PARA Weekly Update: November 7, 2018

2019 CPT® CODE SET RELEASE

PARA is in receipt of the pre-production 2019 CPT® Code Update release. In the coming weeks, our staff
will begin preparing the mapping files for the January 1, 2019 coding update. The CPT® update consists
of the following:
- 212 Added Codes
- 73 Deleted Codes
- 50 Revised Codes
The 2019 Appendix B (Summary of Additions, Deletions, and Revisions) is available within the PDE
Calculator tab and the data is in several formats.
To view the Additions, Changes, or Deletions by type, there are separate radio buttons:

14

PARA Weekly Update: November 7, 2018

2019 CPTÂŽ CODE SET RELEASE

An electronic copy of the Appendix B is available by clicking the ?Changes? hyperlink:

And updates to Coding Guidelines are available at the ?Guidelines? hyperlink:

When the HCPCS code update is released in November, those changes will be incorporated into the mapping files
created for our clients to prepare for the January 1 implementation of new codes. If you have any questions or
require assistance with the Calculator, please contact your PARA Account Executive or your Technical Support
person, listed on the Select tab of the PDE.
15

PARA Weekly Update: November 7, 2018

RURAL HOSPITAL PROGRAM GRANTS AVAILABLE

Rural hospitals and clinics face their own set of unique and burdensome challenges when it comes to
program development, cash management and maintaining volume. That's why it's great when they can
get some assistance from external funding sources.
At PARA, we've found an excellent source of funding opportunities for rural healthcare facilities.
Here are some examples.

Healthy Start: Eliminating Disparities In Prenatal Health
- Provides up to $950,000 for each of
five years for programs that improve
access to quality healthcare and
services for women, infants,
children, and families through
outreach, care coordination,
health education, and linkage to
health insurance
- Strengthen the health
workforce, specifically those individuals responsible for providing direct services
- Application Deadline: November 27,2018

HRSA Remote Pregnancy Monitoring
Challenge Grant
- Provides up to $150,000 to support
technological solutions to help prenatal care
providers remotely monitor the health and well
being of pregnant women
- Priority is given to benefit women in rural and
medically underserved areas.
- Application Deadline:
November 27, 2018

Small Rural Hospitals Improvement Program (SHIP)
- Provides $12,000 for each of four years to help hospitals with 49 or fewer beds
to purchase hardware, software and training
- To join or become accountable care organizations and/or create shared savings
programs
- Purchase health information
technology, equipment or training to
comply with quality improvement
activities.
- Application Deadline:
January 3, 2019
16

PARA Weekly Update: November 7, 2018

MLN CONNECTS
PARA invites you to check out the mlnconnects page available from the Centers For Medicare and
Medicaid (CMS). It's chock full of news and information, training opportunities, events and more! Each
week PARA will bring you the latest news and links to available resources. Click each link for the PDF!

PARA HealthCare Analytics has provided a list of enhancements and updates
that our Information Technology (IT) team has made to the PARA Data Editor
this past week.
This is a NEW Weekly
Feature.
The following table
includes which version of
the PDE was updated,
the location within the
PDE, and a description of
the enhancement.

Week ly IT
Updat e

Week Ending Nov ember 2, 2018

18

PARA Weekly Update: November 7, 2018

There were THREE new or revised Med Learn
(MLN Matters) articles released this week.
To go to the full Med Learn document simply
click on the screen shot or the link.

3

FIND ALL THESE MED LEARNS
IN THE ADVISOR TAB OF THE PDE

19

PARA Weekly Update: November 7, 2018

The link to this Med Learn MM10962

20

PARA Weekly Update: November 7, 2018

The link to this Med Learn MM10955

21

PARA Weekly Update: November 7, 2018

The link to this Med Learn MM11004

22

PARA Weekly Update: November 7, 2018

There were TWENTY-TWO new or revised
Transmittals released this week.
To go to the full Transmittal document simply click
on the screen shot or the link.